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NUCLEAR MEDICINENUCLEAR MEDICINE ININDIAGNOSIS AND TREATMENT OF DIAGNOSIS AND TREATMENT OF Thyroid DISEASESThyroid DISEASES
M.MoslehiM.Moslehi
Nuclear physicianNuclear physician
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Diagnostic AimDiagnostic Aim
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Imaging MethodsImaging Methods
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Advantages of Thyroid Advantages of Thyroid Scintigram over other Imaging Scintigram over other Imaging TechniquesTechniques
Allowing correlation of physical Allowing correlation of physical exam and anatomical imaging exam and anatomical imaging findings with physiology.findings with physiology.
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PATIENT PREPARATIONPATIENT PREPARATION
Need to cease anti thyroid drugs or thyroxine Need to cease anti thyroid drugs or thyroxine replacement prior to scanning - ( in consultation replacement prior to scanning - ( in consultation with the referring doctor).with the referring doctor).
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Scanning Techniques & Scanning Techniques & DevicesDevices
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Scanning Techniques & Scanning Techniques & DevicesDevices
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Scanning Techniques & Scanning Techniques & DevicesDevices
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Radiopharmaceuticals
• Tc-99m pertechnetate– Trapped but non-organified – fast release
– E=140 keV, T/2=6 hours
• I-123– Optimal for diagnosis – pure gamma emitter
– E=159 keV, T/2=13 hours
• I-131– Used for therapy (beta radiation)
– Egama=364 keV, T/2=8 days
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The thyroid
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RADIONUCLIDE GENERATORSRADIONUCLIDE GENERATORS allow to separate chemically short-allow to separate chemically short-lived radioactive daughter nuclei with good characteristics for medical lived radioactive daughter nuclei with good characteristics for medical imaging from long-lived radioactive parent nuclei.imaging from long-lived radioactive parent nuclei.
Milking cow analogy
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Comparison of lifespan death risk from nuclear Comparison of lifespan death risk from nuclear medicine procedures with the lifespan death medicine procedures with the lifespan death risk of smoking, driving in a highway and risk of smoking, driving in a highway and natural irradiationnatural irradiation
Type of scanType of scan DoseDose SmokingSmokingNo. of No. of
cigarettescigarettes
DrivingDrivingIn a In a
highwahighwayy
Brain scanBrain scan 2020((mCimCi))99m99mTc HMPAOTc HMPAO
149149 582582( ( KmKm))
BoneBone 202099m99mTc MDPTc MDP
7979 308308
KidneyKidney22 202099m99mTc DTPATc DTPA
4444 171171
Myocardial scanMyocardial scan 20-4020-4099m99mTc sestimibiTc sestimibi
164164 639639
Lung perfusion Lung perfusion scanscan
55 99m99mTc MAATc MAA
2828 109109
Lung Ventilation Lung Ventilation scanscan
101081m81mKrKr
<<11 0.50.5
Thyroid scanThyroid scan 5599m99mTc Tc
pertecnetatepertecnetate
2828 110110
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INTERNATIONAL COMMISSION ON INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION RADIOLOGICAL PROTECTION ————————————————————————————————————————————————————————— ———————————————————
Nuclear medicine and Nuclear medicine and pregnant patientspregnant patients……Most diagnostic procedures are done with Most diagnostic procedures are done with
short-lived radionuclides (such as short-lived radionuclides (such as technetium-99technetium-99mm) that do not cause large ) that do not cause large fetal dosesfetal doses
Often, fetal dose can be reduced through Often, fetal dose can be reduced through maternal hydration and encouraging voiding maternal hydration and encouraging voiding of urineof urine
Some radionuclides do cross the placenta Some radionuclides do cross the placenta and can pose fetal risks (such as iodine-131)and can pose fetal risks (such as iodine-131)
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INTERNATIONAL COMMISSION ON INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION RADIOLOGICAL PROTECTION ————————————————————————————————————————————————————————— ———————————————————
Nuclear medicine and Nuclear medicine and pregnant patient (cont’d)pregnant patient (cont’d)
The fetal thyroid accumulates iodine after The fetal thyroid accumulates iodine after about 10 weeks gestational ageabout 10 weeks gestational age
High fetal thyroid doses from radioiodine High fetal thyroid doses from radioiodine can result in permanent hypothyroidismcan result in permanent hypothyroidism
If pregnancy is discovered within 12 h of If pregnancy is discovered within 12 h of radio-iodine administration, prompt oral radio-iodine administration, prompt oral administration of stable potassium iodine administration of stable potassium iodine (60-130 mg) to the mother can reduce (60-130 mg) to the mother can reduce fetal thyroid dose. This may need to be fetal thyroid dose. This may need to be repeated several timesrepeated several times
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Recommendations for cessation of breast Recommendations for cessation of breast
feedingfeeding radiopharamceutradiopharamceut
icicdosedose Imaging Imaging
procedureprocedureCessation Cessation
timetime
Tc-pertechnetateTc-pertechnetate 55 mcimci Thyroid scanThyroid scan 2424 hrshrs
Tc-DTPATc-DTPA 10-15mci10-15mci Renal scanRenal scan 1717 hrshrs
Tc-SCTc-SC 5mci5mci Liver-spleen Liver-spleen scanscan
1515 hrshrs
Tc-MDPTc-MDP 15-25mci15-25mci Bone scanBone scan 1717 hrshrs
Ga-67Ga-67 6-10mci6-10mci Infection and Infection and tumor scantumor scan
44 wkswks
TL-201TL-201 3mci3mci Myocardial Myocardial perfusion scanperfusion scan
33 wkswks
I-131I-131 10micro and 10micro and moremore
Thyroid scan Thyroid scan and therapyand therapy
discontinuediscontinue
TC-MAATC-MAA 3-5mci3-5mci Lung perfusion Lung perfusion scanscan
1010 hrshrs
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Which oneWhich one??
I-131:I-131: is not the agent of choice is not the agent of choice for routine diagnostic for routine diagnostic scintigraphies (because of high scintigraphies (because of high energy emissions and the long energy emissions and the long half life).half life).
Technetium-99m:Technetium-99m: A frequently A frequently used alternative.used alternative.
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Physical Characteristics of Physical Characteristics of Tc-99mTc-99m
Half life: 6 hrHalf life: 6 hr
Generator producedGenerator produced
Usual dose: 3-10 millicurieUsual dose: 3-10 millicurie
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Tc-99m Thyroid Tc-99m Thyroid Scintigraphy: ApplicationsScintigraphy: Applications
Further evaluation of findings on physical Further evaluation of findings on physical examination.examination.
To determine the functional status of To determine the functional status of thyroid nodules.thyroid nodules.
Detection of extrathyroidal tissue (such Detection of extrathyroidal tissue (such as lingual thyroid).as lingual thyroid).
Differential diagnosis of hyperthyroidism.Differential diagnosis of hyperthyroidism.
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Normal Thyroid Normal Thyroid ScintigramScintigram
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Normal Thyroid ScintigramNormal Thyroid Scintigram
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Thyroid NoduleThyroid Nodule
The major challenge is to determine The major challenge is to determine whether a thyroid nodule is benign whether a thyroid nodule is benign or malignantor malignant
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Most important tools in the Most important tools in the assessment of thyroid nodulesassessment of thyroid nodules
History and clinical examHistory and clinical exam
Thyroid Function TestsThyroid Function Tests
Fine Needle Aspiration (FNA)Fine Needle Aspiration (FNA)
Thyroid ScanThyroid Scan
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Scintigraphy in Evaluation of Scintigraphy in Evaluation of Thyroid NodulesThyroid Nodules
Can not be used to exclude or confirm Can not be used to exclude or confirm the malignancy.the malignancy.
FNA with Scintigraphy is a more direct FNA with Scintigraphy is a more direct meansmeans
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Scintigraphic classification of Scintigraphic classification of thyroid nodulesthyroid nodules
Cold (Hypofunctioning)Cold (Hypofunctioning)
Hot (Functioning)Hot (Functioning)
Indeterminate: Function Indeterminate: Function equals to that of surrounding equals to that of surrounding normal thyroidnormal thyroid
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A Functional Thyroid A Functional Thyroid NoduleNodule
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A Functional Thyroid A Functional Thyroid NoduleNodule
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Thyroid Nodules (continue)Thyroid Nodules (continue)
• Nonfunctioning nodules appear cold and Nonfunctioning nodules appear cold and require further evaluation by FNA. require further evaluation by FNA.
• Autonomously functioning nodules may Autonomously functioning nodules may appear hot . Only a few patients with appear hot . Only a few patients with autonomous nodules have been found to autonomous nodules have been found to have thyroid cancer , and only a few of have thyroid cancer , and only a few of these cancers were aggressive . these cancers were aggressive . Furthermore, in some of these patients, Furthermore, in some of these patients, the cancer was adjacent to the the cancer was adjacent to the autonomous nodule rather than within it.autonomous nodule rather than within it.
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Multinodular GoiterMultinodular Goiter
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Multinodular GoiterMultinodular Goiter
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Cold NoduleCold Nodule
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Cold NoduleCold Nodule
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Differential Diagnosis of Differential Diagnosis of thyrotoxicosisthyrotoxicosis
GraveGrave’’s Diseases Disease
Toxic Multinodular goiterToxic Multinodular goiter
Toxic AdenomaToxic Adenoma
ThyroiditisThyroiditis
Thyrotoxicosis FactitiaThyrotoxicosis Factitia
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GraveGrave’’s Diseases Disease
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GraveGrave’’s Diseases Disease
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ThyroiditisThyroiditis
Clinical Picture (can be confusing)Clinical Picture (can be confusing)
Plasma Levels of Thyroid Plasma Levels of Thyroid Hormones (may be misdiagnosed Hormones (may be misdiagnosed as Graveas Grave’’s Dis.)s Dis.)
Scan PatternScan Pattern
RAIURAIU
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Subacute thyroiditis
Tc-99m pertechnetate
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Ectopic Thyroid TissueEctopic Thyroid Tissue
lingual, substernal, pelvic/ovarian lingual, substernal, pelvic/ovarian teratoma (struma ovarii)teratoma (struma ovarii)
Pertechnetate is not useful for Pertechnetate is not useful for imaging the substernal area due to imaging the substernal area due to attenuation or superimposed blood attenuation or superimposed blood pool activitypool activity
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Thyroglossal duct cystThyroglossal duct cyst
Midline along the migratory path of the embryologic gland, Midline along the migratory path of the embryologic gland, anywhere from the foramen cecum at the base of the anywhere from the foramen cecum at the base of the tongue to the lower necktongue to the lower neck
The vast majority of patients have normal thyroid scans.The vast majority of patients have normal thyroid scans.
Complications: Infection, and rarely papillary thyroid Complications: Infection, and rarely papillary thyroid carcinomacarcinoma
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Physical Characteristics of I-131Physical Characteristics of I-131
Half-life of 8.05 days Half-life of 8.05 days
Emits a high energy gamma (364 Emits a high energy gamma (364 keV) and particulate emissions keV) and particulate emissions
Reactor producedReactor produced
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Dose of I-131Dose of I-131
DiagnosticDiagnostic
1.1. Retrostenal Goiter: 50-200 MicrocurieRetrostenal Goiter: 50-200 Microcurie
2.2. whole body scans for following of whole body scans for following of thyroid carcinoma: 2-5 mCithyroid carcinoma: 2-5 mCi
TherapeuticTherapeutic1.1. Non-neoplastic applications: 5-29 mCiNon-neoplastic applications: 5-29 mCi
2.2. Differentiated thyroid CA: 100-200 mCiDifferentiated thyroid CA: 100-200 mCi
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I-131 Thyroid Scintigraphy: I-131 Thyroid Scintigraphy: ApplicationsApplications
Evaluation of a substernal massEvaluation of a substernal mass
Detection of persistent residual Detection of persistent residual tissue after thyroid surgery for DTCtissue after thyroid surgery for DTC
Detection of regional cervical lymph Detection of regional cervical lymph node involvement or distant node involvement or distant metastatic involvementmetastatic involvement
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Substernal Thyroid MassesSubsternal Thyroid Masses
I-131 is the preferred imaging agent due to I-131 is the preferred imaging agent due to mediastinal blood pool activity with Tc-99m mediastinal blood pool activity with Tc-99m and significant attenuation of low energy and significant attenuation of low energy gamma photons by sternum gamma photons by sternum
Most intra-thoracic goiters demonstrate Most intra-thoracic goiters demonstrate anatomic continuity, but not necessarily anatomic continuity, but not necessarily functional continuity with cervical thyroid functional continuity with cervical thyroid tissue.tissue.
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Multinodular Goiter with Multinodular Goiter with Retrosternal ExtensionRetrosternal Extension
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Radioactive Iodine Uptake Radioactive Iodine Uptake Test (RAIU)Test (RAIU)
useful assessment of thyroid useful assessment of thyroid function function
the higher the iodine uptake, the the higher the iodine uptake, the more active the gland more active the gland
Normal 24 hour RAIU = 8 to 35% Normal 24 hour RAIU = 8 to 35%
Normal 4 hour RAIU = 5 to 15%Normal 4 hour RAIU = 5 to 15%
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IndicationsIndicationsTo confirm hyperthyroidism To confirm hyperthyroidism
To calculate therapeutic dose of I-131 To calculate therapeutic dose of I-131
To determine the cause of To determine the cause of thyrotoxicosisthyrotoxicosis
** high RAIU uptake in "true ** high RAIU uptake in "true hyperthyroidismhyperthyroidism““
** low RAIU in thyroiditis or who ** low RAIU in thyroiditis or who abuse thyroid abuse thyroid hormoneshormones
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Therapeutic AimTherapeutic Aim
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γγ-emitters-emitters
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ββ-emitters-emitters
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Radiation toxicityRadiation toxicity
• Critical site Critical site – stem cells of bone marrow stem cells of bone marrow
• May be affectedMay be affected– LiverLiver– ThyroidThyroid– Urinary tract Urinary tract
• SometimesSometimes– Normal tissue adjacent to the target Normal tissue adjacent to the target
tissue tissue
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131131I therapyI therapy
• IndicationsIndications– Thyroid carcinomaThyroid carcinoma– ThyrotoxicosisThyrotoxicosis– Non-toxic goiterNon-toxic goiter
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Results (Results (in hyperthyroidism)in hyperthyroidism)
Cure > 90% with a single doseCure > 90% with a single dose
Most patients eventually become Most patients eventually become hypothyroid (need for replacement hypothyroid (need for replacement hormone therapy)hormone therapy)
Lower risk of hypothyroidism after Lower risk of hypothyroidism after treatment of solitary hyperfunctioning treatment of solitary hyperfunctioning nodulesnodules
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I-131 Therapy For Nontoxic I-131 Therapy For Nontoxic GoitersGoiters
Reduction of thyroid volume in Reduction of thyroid volume in patients with non-toxic patients with non-toxic multinodular goiter. multinodular goiter.
Goiter size can decreased by about Goiter size can decreased by about 40% after 1 year and 50-60% after 40% after 1 year and 50-60% after 3 to 5 years 3 to 5 years
The dose is approximately 100 uCi The dose is approximately 100 uCi of I-131 per gram of thyroid tissue, of I-131 per gram of thyroid tissue, corrected for RAIU at 24 hourscorrected for RAIU at 24 hours
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Important Contra-indications For Important Contra-indications For Treatment of HyperthyroidismTreatment of Hyperthyroidism
Pregnancy should be ruled Pregnancy should be ruled out (avoiding of pregnancy 6 out (avoiding of pregnancy 6 to 12 months after treatment) to 12 months after treatment)
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Minimal ComplicationsMinimal Complications
No statistically significant increase in thyroid and No statistically significant increase in thyroid and other malignanciesother malignancies
No reduction in fertilityNo reduction in fertility
No congenital defect in children of treated individualsNo congenital defect in children of treated individuals
Thyroid storm after therapy as a riskThyroid storm after therapy as a risk
Local neck pain, tenderness and swelling for few Local neck pain, tenderness and swelling for few daysdays
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INTERNATIONAL INTERNATIONAL COMMISSION ON COMMISSION ON
RADIOLOGICAL RADIOLOGICAL PROTECTION PROTECTION ————————— —————————————————— —————————————————— —————————————————— ——————————— ——
Pre-conception irradiationPre-conception irradiationPre-conception irradiation of either Pre-conception irradiation of either
parent’s gonads has parent’s gonads has notnot been shown to been shown to result in increased risk of cancer or result in increased risk of cancer or malformations in childrenmalformations in children
This statement is from comprehensive This statement is from comprehensive studies of atomic bomb survivors as studies of atomic bomb survivors as well as studies of patients who had well as studies of patients who had been treated with radiotherapy when been treated with radiotherapy when they were childrenthey were children
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Instructions for the Patient Instructions for the Patient (Received 131-I 5-29 mci)(Received 131-I 5-29 mci)
1.1. Avoid close contact with children and Avoid close contact with children and pregnant women for at least the first pregnant women for at least the first 2 days (occasional hug is not harmful)2 days (occasional hug is not harmful)
2.2. Maintain a careful distance from Maintain a careful distance from others for at least the first 2 days others for at least the first 2 days (two arm lengths).(two arm lengths).
3.3. Sleep alone in a room for at least the Sleep alone in a room for at least the first night.first night.
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Instruction for the Patient Instruction for the Patient (cont,)(cont,)
4.4. Do not travel by airplane or mass Do not travel by airplane or mass transportation for at least the first day.transportation for at least the first day.
5.5. Do not travel on a prolonged Do not travel on a prolonged automobile trip ( >2 hours) with automobile trip ( >2 hours) with others for at least the first 2 days.others for at least the first 2 days.
6.6. Flush the toilet 3 times after use.Flush the toilet 3 times after use.
7.7. Avoid mouth to mouth contact for at Avoid mouth to mouth contact for at least 1 weekleast 1 week
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Instruction for the Patient Instruction for the Patient (cont,)(cont,)
8.8.Clothing worn during the first 3 days Clothing worn during the first 3 days after the therapy dose that was after the therapy dose that was directly in contact with skin should directly in contact with skin should be laundered separately. be laundered separately.
9.9.Drink plenty of extra fluids for 2 Drink plenty of extra fluids for 2 daysdays
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Radiation detectors at ports of Radiation detectors at ports of entryentry
• It is possible that patients treated It is possible that patients treated with 131I could trigger alarms at with 131I could trigger alarms at such detection sites for 95 days or such detection sites for 95 days or longer after treatment.longer after treatment.
• If, within 4 months of receiving 131I If, within 4 months of receiving 131I therapy, travel is planned a form therapy, travel is planned a form should be provided to the patientshould be provided to the patient
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Contraindication of 131-I Contraindication of 131-I therapytherapy
• PregnancyPregnancy
• Breast feedingBreast feeding
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Contraindication of 131-I Contraindication of 131-I therapytherapy• A pregnancy test must be performed before A pregnancy test must be performed before
thethe
time (usually within 72 hours).time (usually within 72 hours).
• Pregnancy should be delayed for at least 6 Pregnancy should be delayed for at least 6 months after radioiodine therapy, a delay months after radioiodine therapy, a delay based on the need to normalize thyroid based on the need to normalize thyroid levels for a successful pregnancy and levels for a successful pregnancy and healthy infant development, and to ensure healthy infant development, and to ensure that additional radiation treatment is not that additional radiation treatment is not imminent.imminent.
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Contraindication of 131-I Contraindication of 131-I therapytherapy• Lactating breast concentrates a substantial Lactating breast concentrates a substantial
amount of iodideamount of iodide
• Breastfeeding must be stopped at least 6 Breastfeeding must be stopped at least 6 weeks before administration of 131I therapy, weeks before administration of 131I therapy, and a delay of 3 months will more reliably and a delay of 3 months will more reliably ensure that lactation-associated increase in ensure that lactation-associated increase in breast sodium iodide symporter activity has breast sodium iodide symporter activity has returned toreturned tonormal. .
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Contraindication of 131-I Contraindication of 131-I therapytherapy
Breast feeding should not be Breast feeding should not be resumed after administration of 131I. resumed after administration of 131I. Breastfeeding can be safely Breastfeeding can be safely undertaken after future Pregnancies.undertaken after future Pregnancies.
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Thank you